GW1-2021-02466_Well Construction - GW1_20210811

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or mutiple wells
4. AT RaZONES r2,
1.Well Contractor Information: y
FROM TO DESCRIPTION
WILLIAM LAWSON 173% 174 ft.
Well Contractor Name 456 It. 457 fL
NCWC3491A 5O_UT,ERCASING(formal"h�rtsed "ORINER(if apP
NC Well Contractor Certification Number FROM TO DIAMETER THICKNES MATERIAL
CHEROKEE WELL DRILLING 0 fi- 80 fL 6.125 iL SOR 21 PVC plastic
Company Name fi- ft. in.
6INNERGASINGOR UBING(geo erlclos 'loop)
2.Well Constmetitm Permit 8: W2021000191 2017000279 FROM TO DIAMETER THICILNES MATERIAL
List all applicable well construction pertmits(re County,State, Variance,eta ft. ft. in.
3.Well Use: It. D' in.
7 SCREEN . ,-x .'
FROM TO DIAMETER THICKNES SLOTS MATERIAL
Residential & ft. in.
fl ft. m
VW
M,
FROM T 2 MATERIAL EMPLACEMENT METHOD&AMOUNT M 0
A��- 1 in9 Uri�� M ft.
]9 SAAII?/GRAB.EL �A�K�Cifa�plica_,e)
FROM_F TO w MATERIAL EMPLACEMENT METHOD&AMOUN
fl. ft.
4. Date Well(s)Completed: 7/29/2021 Well ID#
8. ft.
Sa. Well Location: 20�'�RLI INGOG attachadihona;sheets5il ecessa a
List all applicable well construction rtmits he C „-"T `
pe panty,State,Variance,etc FROM DESCRL'TIOr �cdlpt;ln�dn.ss;sou1,�1C
lam'grainrv)
DAKOTA BRETT MCDONALD
0 ttt 58 ft Red Medium Slate
Facility/Owner Name Facility ID(if applicable) 58& 80 ft. Gray Hard Slate SET CASING
865 FALL BRANCH RD MURPHY 28906 Lot 80 f1. 173 ft. Gray Hard Slate
Physical Address;City,and Zip 173& 174 ft. Fractured SMALL FISSURE 0:5 GPM
Cherokee 551201070130000 174 tl. 456 ft. Gray Hard Granite
County Parcel Identification No.(PIN) 456 ft. 457 f1. Fractured SMALL FISSURE 4 GPM
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 457 ft. 505 ft. Gray Hard Granite
2MARKS
(If well field,one IaUlong is sufficient) PRE
35.095977 N -83.98302 W BIT SIZE 5.98"
6. Is(are)the well(s): Permanent
22. CertificZ;�9�
7. Is this a repair to an existing well: No8/6/2021
if this is a repair,fill out known well construction information and explain the nature of the Signature of Certe'ied Well Contractor Date
repair under#21 remarks section or on the back of this form. By signing this form,I hereby certify that the wells)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
& Number of wells constructed: 1 copy of this record has been provided to the wall owner.
For multiple injection or non-water wells ONLY with the same construction,you can 23. Site diagram►or additional well details:
submit one form. You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
9.Total well depth below land surface: 505 (M)
For multiple wells list all depths tf different(example-3G 200'and 2 Qa 1009 SUAIITTAL INSTRUCTIONS
10.Static water level below top of casing: 80 (ft-) 24a.For All Wells: Submit this form within 30 days of completion of well
construction to the following:
If water level is above casing use"+"
Division of Water Quality,Information Procession Unit,
11. Borehole diameter: 6 (in.) 1617 Mail Service Center,Raleigh,NC 27699-1617
12. Well construction method: Rotary air 24b.For Infection Wells: In addtion to sending the form to the address in 24a
(Le.auger,rotary,cable,direct push,etc.) above,also submit a copy of this form within 30 days of completion of well
construction to the following
FOR WATER SUPPLY WELLS ONLY: Division of Water Quality„Undergroun Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 4.5 Method of test: Air 24c.For Water Supply Infection Wells: hi addtion to sending the form to
the address(es)above;also submit one copy of this form within 30 days of
13b. Disinfection type: HTH Amount: 30 completion of well construction to the county health department of the county
where constructed.
i
Form GW-1 North Carolina Department of Environment and Natural Resources - Division of Water Ouuality Revised Jan 2013